Eventually, Koenig said that Sodini may have deteriorated to a state in which he was unable to respond to efforts to reach out to him and had resolved to ignore anything that might shift focus from his "plan."
"Unfortunately, I talked to my neighbor today who is very positive and upbeat," Sodini wrote on Aug. 3, 2009, the day before he opened fire in the fitness center. "I need to remain focused and absorbed COMPLETELY. Last time I tried this, in January, I chickened out. Lets see how this new approach works."
Madelyn Fernstrom, professor of psychiatry at the University of Pittsburgh Medical Center, said that a professional evaluation to determine if talk therapy, medication or an inpatient stay in the case of evidence of self-harm or harm to others would have been the best option for Sodini to help stabilize his behavior.
But even an assessment may not be the only step toward separating intent from fantasy in a patient.
"It would clearly be an ethical challenge for a therapist to determine if a patient saying these things fell into the category of 'duty to protect,' [which requires an identifiable victim]," Binks said. "But one would very likely seriously consider involuntary commitment in a case such as this."